Weighing In on Medical Management of Obesity FATIMA CODY STANFORD, MD, MPH, MPA, FAAP, FTOS OBESITY MEDICINE & NUTRITION, MGH WEIGHT CENTER AMERICAN BOARD OF OBESITY MEDICINE DIPLOMATE
Disclosures Consultant for Novo Nordisk
Clinical Questions What is the approach to the patient who has difficulty losing weight? Which labs and elements of the history and physical are helpful to management? What are considerations for prescribing medications for weight reduction, and what is the recommended follow up for maximizing success with theses patients? When are surgical interventions indicated, and how should patient be prepared for this consultation?
Body Mass Index Calculation Metric measurements: Weight (kg) Height (m) 2 English measurements: Weight (lb) X 703 Height (in) 2
How is Obesity defined in Adults? Weight Status Category Body Mass Index (BMI) Underweight < 18.5 Normal Weight 18.5-24.9 Overweight 25- 29.9 Class I Obesity 30-34.9 Class II Obesity 35-39.9 Class III Obesity ≥40
Prevalence ¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011 ¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence ¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2012 ¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence ¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013 ¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence ¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2014 ¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence ¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2015 ¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Energy Balance (simple)
Energy Balance (simple)
Energy Balance (more complex) Clin Sci (Lond). 2016 Sep 1;130(18):1615-28.
All Calories are NOT created EQUAL
Obesity: A Multi-factorial Disorder Genetics Environment Development Behavior
Regulation of Food Intake http://www.cellbiol.net/ste/alpobesity2.php
Regulation of Food Intake Nature Reviews Genetics 10 , 431-442 (July 2009)
Central Nervous System regulates weight
Contributors/ Influencers to Obesity Food & Biological/ Beverage Maternal/ Medical Behavior/ Developmental Environment Social Psychological Economic Environmental Pressures on Physical Activity
Contributors to Obesity- Inside the Person ↑Intake ↑ Intake/ ↓ Expenditure ↓Expenditure Hyper-reactivity to Genetic and Environmental Food Gut Microbiota Epigenetic Factors Cues Delayed Satiety Thermogenesis Age Related Changes Disordered Eating Physical Disabilities Mood Disturbances
Contributors to Obesity- Outside the Person ↑Intake ↑ Intake/ ↓Expenditure ↓Expenditure Environmental/ Built Environment Stress Chemical Toxins Pervasive Sedentary Time Weight Cycling Food advertising Labor Saving Maternal/Paternal Large Portion Sizes Devices Obesity
Weight Bias in Healthcare Obes Rev. 2015 Apr; 16(4): 319 – 326.
Circulation. 2014 Jun 24;129(25 Suppl 2):S102-38.
Initial Steps to Assess Patients with Obesity (AHA/ACC/TOS guidelines) Patient Encounter Measure Height, Weight, and Calculate BMI Determine Weight Category Assess and Treat CVD risk factors and obesity related co-morbidities Assess Weight and Lifestyle Histories
Assess and treat CVD risk factors and obesity related co-morbidities History and physical examination Clinical and laboratory assessments Blood pressure Fasting blood glucose Fasting lipid panel (expert opinion) Waist circumference measurement (BMI 25- ≤ 35) (>88 cm or >35 in for women and >102 cm or >40 in for men Intensive Management of CVD risk factors (these and host of others): Hypertension Dyslipidemia Prediabetes/ Diabetes Obstructive Sleep Apnea (OSA)
Assess Weight and Lifestyle Histories Ask questions about history of weight gain and loss over time Details of previous weight loss attempts Dietary habits Physical activity Family history of obesity Other medical conditions or medications that may affect weight
Next Steps to Assess Patients with Obesity Assess need to lose weight Advise to avoid weight gain and address other risk factors Assess readiness to make change and identify barriers to success Determine weight loss and health goals and intervention strategies Comprehensive lifestyle therapies alone or in conjunction with adjunctive therapies
Guidelines for Selecting Obesity Treatment BMI Category Treatment 25-26.9 27-29.9 30- 35-39.9 ≥40 34.9 + + + Diet, PA, & Behavioral With With Therapy co-morbidities co-morbidities Pharmacotherapy With + + + co-morbidities Weight Loss Surgery With co-morbidities • Prevention of weight gain with lifestyle therapy is indicated in any patient with a BMI ≥ 25 kg/m2 , even without co-morbidities, while weight loss is not necessarily recommended for those with a BMI of 25 – 29.9 kg/m2 or a high waist circumference, unless they have two or more co-morbidities. • Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy. The + represents the use of indicated treatment regardless of co-morbidities.
Common Weight Promoting Medications Anti-psychotics Sleep Agents Zolpidem Risperidone Eszopiclone Lithium Trazadone Quetiapine Zaleplon Aripiprazole Neuropathic Agents Olanzapine Gabapentin Pregablin Valproic Acid • β -Blockers Anti-depressants • Steroids Citalopram • Insulin Duloxetine • Hypoglycemic Agents Venlafaxine
Treatment Strategy for Weight Promoting Medications Investigate whether medications are a likely source of weight gain in patients. If a weight promoting drug may be discontinued, discontinue the agent. If discontinuation of a weight promoting medication is not feasible, consider the use of anti-obesity pharmacotherapy for weight loss in conjunction with appropriate lifestyle changes.
Anti-obesity pharmacotherapy agents Most agents may be characterized into 3 primary groups 1) Centrally acting medications that impair dietary intake 2) Medications that act peripherally to impair dietary absorption 3) Medications that increase energy expenditure
FDA Approved Anti-obesity pharmacotherapy agents Drug class/name CNS Stimulants/ Anorexiants: Phentermine *Phentermine/topiramate *Lorcaserin Diethylpropion Phendimetrazine Benzphetamine Anti-Depressants/ Dopamine Reuptake Inhibitors/ Opioid Antagaonists: *Bupropion/ Naltrexone Gastrointestinal Agents/Other: *Orlistat *GLP-1 agonists (liraglutide)
Other Anti-obesity pharmacotherapy agents Drug class/name Topiramate Zonisamide Bupropion Metformin Amylin agonist (pramlinitide) SGLT2 Inhibitors (canagliflozin, dapaglifozin)
Criteria for Weight Loss Surgery Body Mass Index (BMI) ≥40 OR BMI of 35-39.9 + 1 serious co-morbidity Type 2 Diabetes Mellitus Coronary Artery Disease Obstructive Sleep Apnea Prior Unsuccessful Weight Loss Attempts Acceptable operative risks Ability to participate in treatment and long term follow-up An understanding of the operation and the lifestyle changes needed to sustain long term weight loss
Most Common Weight Loss Surgeries in the US Roux-en-Y Gastric Bypass Vertical Sleeve Gastrectomy
Case #1 54 year old woman Past medical history: Untreated hypertension Migraine headaches GERD Irritable Bowel Syndrome Metabolic syndrome Retained 20 lbs with each of her 2 pregnancies Tried many commercial programs which lead to 20 lbs of unsustainable weight loss with each attempt Most significant weight loss with the use of phen-fen in the 1990's (~50 lbs over 6 months) Interested in weight loss medications + behavioral Tx
54 year old woman BMI: 40 Topiramate Behavioral BMI: 30 BMI: 31 BMI: 28.5 Phentermine
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